Basics

Description

An acute infection of the upper genital tract in women caused by the ascent of sexually transmitted infections (STIs) from the vagina and endocervix to the uterus, fallopian tubes, ovaries, and contiguous structures.

Pelvic inflammatory disease (PID) is a broad term that encompasses a variety of upper genital tract infections, including endometritis, salpingitis, oophoritis, tubo-ovarian abscess, peritonitis, and perihepatitis.

Accurate diagnosis is challenging and incorrect in up to 1/3 of women.

Annual chlamydia screening of all sexually active women aged <25 years and of older women with risk factors (e.g., those who have a new sex partner or multiple sex partners

Routine STI screening in pregnancy

Evaluation and treatment of sexual partners after diagnosis with STI

Pathophysiology

The precise mechanism by which microorganisms ascend from the lower genital tract is not known. One possibility is that chlamydial or gonococcal endocervicitis disturbs the vaginal ecosystem, allowing ascent of the vaginal flora with or without the original pathogen. Thus, polymicrobial infection can occur without Neisseria gonorrhoeae or C. trachomatis infection.

75% of cases occur within 7 days of menses, when the cervical mucous favors ascension of organisms.

Etiology

Multiple organisms act as etiologic agents in PID. Most cases are polymicrobial.

C. trachomatis, N. gonorrhoeae and a wide variety of aerobic and anaerobic bacteria are recognized as etiologic agents.

The proportion of cases infected with chlamydia or gonorrhea varies widely depending on the population studied.

The most common organisms include H. influenzae, streptococcus pyogenes, Bacteroides, E. coli, Peptococcus, and Peptostreptococcus sp.

Bacterial vaginosis is more common among women with PID but does not confer and increased risk of PID.

Mycoplasmas also have been implicated, but their role is less clear.

Commonly Associated Conditions

If PID is suspected in a patient with a long-term indwelling IUD and a pelvic abscess is present, an Actinomyces infection requiring penicillin treatment may be present.

Rupture of an adnexal abscess is rare but life-threatening. Early surgical exploration is mandatory.

Chlamydial or gonococcal perihepatitis may occur with PID. This combination is called Fitz-Hugh-Curtis syndrome and is characterized by severe pleuritic right upper quadrant pain. FHC complicates 10% of PID.

Diagnosis

It is wiser to overtreat a lower tract genital infection than to miss an upper tract infection.

For the diagnosis of PID, the Centers for Disease Control and Prevention (CDC) recommend only a minimal diagnostic criterion of cervical motion, uterine or adnexal tenderness in the presence of lower abdominal pain.

History

PID diagnosis is elusive, and even asymptomatic patients are at risk for sequelae.

Fever (50%)

Nausea and vomiting

Lower abdominal pain, worse with coitus and jarring movements

New/abnormal vaginal discharge

Irregular bleeding occurs in ≥1/3 patients

Urinary discomfort

Proctitis

Physical Exam

Criteria for diagnosis:

Lower abdominal/suprapubic pain (+/- rebound)

Adnexal tenderness (unilateral or bilateral)

Cervical motion tenderness

Supports diagnosis:

Temperature ≥38.3°C

Cervical or vaginal mucopurulent discharge

Diagnostic Tests & Interpretation

Lab

Initial lab tests

Pregnancy test – must be performed to rule out ectopic pregnancy and complications of an intrauterine pregnancy

Several antibiotic regimens are highly effective, with no single regimen of choice, but coverage should include Chlamydia, gonorrhea, anaerobes, gram-negative rods, and streptococci. CDC regimens that follow are recommendations, and the specific antibiotics named are examples.

On the basis of the recent emergence of fluoroquinolone-resistant gonococci, the CDC no longer recommends the use of these agents for the treatment of gonococcal infections and associated conditions such as PID.

Only cephalosporins are still recommended (1)[A].

Second Line

Many other antibiotic regimens have been proposed and used with success, for example, tobramycin in place of gentamicin or tetracycline in place of doxycycline (2).

In persons with documented severe allergic reactions to penicillins or cephalosporins, azithromycin or spectinomycin might be an option for therapy of uncomplicated gonococcal infections (1)[A].

Additional Treatment

General Measures

Patient should avoid sex until treatment is completed.

Refer sex partners for appropriate evaluation and treatment. Partners should be treated, irrespective of evaluation, with regimens effective againstChlamydia and gonorrhea.

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